Analyze the subjective portion of the note.

  • Analyze the subjective portion of the note. List additional information that should be included in the documentation.
  • Analyze the objective portion of the note. List additional information that should be included in the documentation.
  • Is the assessment supported by the subjective and objective information? Why or why not?
  • Would diagnostics be appropriate for this case, and how would the results be used to make a diagnosis?
  • Would you reject/accept the current diagnosis? Why or why not?  Identify three possible conditions that may be considered as a  differential diagnosis for this patient. Explain your reasoning using at  least three different references from current evidence-based  literature.

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